A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/minute.
Resting respiratory rate of 35 breaths/minute.
The Correct Answer is A
Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While using gestures with 1 to 2 word sentences is a developmental milestone, it is typically seen in younger children, around the age of 212.
Choice B rationale
Using 1 word sentences is a developmental milestone usually achieved by children around the age of 112. By the age of 3, children are typically able to speak in simple sentences with four or more words.
Choice C rationale
Speaking in simple sentences with four or more words is a typical developmental milestone for a 3-year-old child. They are able to express their thoughts more clearly and engage in conversations.
Choice D rationale
Recognizing most letters and numbers is a skill that is typically developed around the age of 4 or 512. Therefore, expecting a 3-year-old child to recognize most letters and numbers might be too advanced for their developmental stage.
Correct Answer is C
Explanation
Choice A rationale
Variance in blood pressure across extremities is not typically associated with ventricular septal defects (VSDs). VSDs are characterized by a hole in the heart that allows oxygen-rich blood to move back into the lungs instead of being pumped to the rest of the body.
Choice B rationale
Hypotension is not a common symptom of VSDs. Instead, these defects can cause increased blood pressure in the lungs due to the abnormal flow of blood.
Choice C rationale
Tachycardia, or a rapid heart rate, is a common symptom of VSDs, especially in cases where the defect is medium or large. This is because the heart needs to work harder to pump blood, leading to an increased heart rate.
Choice D rationale
While pulse oximetry readings within defined limits could be seen in small VSDs, in larger defects or those causing heart failure, oxygen saturation levels might be lower due to the abnormal circulation of blood.
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